View Information Collection Request (ICR) Package
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Brief and OIRA conclusion
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FR Notices/Comments
IC List
Burden
Misc.
Common Form Info.
Certification
View Information Collection (IC) List
View Supporting Statement and Other Documents
Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0938-0999
ICR Reference No:
201211-0938-010
Status:
Historical Active
Previous ICR Reference No:
200706-0938-011
Agency/Subagency:
HHS/CMS
Agency Tracking No:
Title:
Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424 Subpart C
Type of Information Collection:
Reinstatement without change of a previously approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
05/15/2013
Retrieve Notice of Action (NOA)
Date Received in OIRA:
11/28/2012
Terms of Clearance:
CMS will report this violation in the ICB in 2013.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
05/31/2016
36 Months From Approved
Responses
988,005,045
0
0
Time Burden (Hours)
21,481,336
0
0
Cost Burden (Dollars)
0
0
0
Abstract:
This form is a standardized claim form foruse in the Medicare/ Medicaid programs to apply for reimbursement for covered services Many private insurers also use this form. Use of this form reduces cost and administrative burdens associated with professional claims because only one format need be used and maintained.
Authorizing Statute(s):
US Code:
42 USC 1395x
Name of Law: DEFINITIONS OF SERVICES, INSTITUTIONS, ETC
US Code:
42 USC 1395k
Name of Law: SCOPE OF BENEFITS
US Code:
42 USC 1395u
Name of Law: PROVISIONS RELATING TO THE ADMINISTRATION OF PART B
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
77 FR 31615
05/29/2012
30-day Notice:
Federal Register Citation:
Citation Date:
77 FR 58558
09/21/2012
Did the Agency receive public comments on this ICR?
Yes
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424 Subpart C
CMS-1500(08-05), CMS-1490-S
Health Insurance Claim Form
,
PATIENT'S REQUEST FOR MEDICAL PAYMENT
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
988,005,045
0
0
0
17,830,785
970,174,260
Annual Time Burden (Hours)
21,481,336
0
0
0
-11,586,421
33,067,757
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Annual Cost to Federal Government:
$3,514,000,000
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
William Parham 4107864669
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
11/28/2012
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